For a relatively soft nucleus, such as in a younger patient with primarily posterior subcapsular cataract changes, the supracapsular technique is an excellent way to perform a safe and efficient surgery,
With a grade of 1 to 2+ nuclear sclerosis, it becomes less effective to perform a nucleo-fractis technique such as phaco chop or divide-and-conquer because the crack does not propagate as well. Using high vacuum to hold the nucleus is also a challenge since the vacuum level will start to eat away at the nucleus before achieving sufficiently high grip. Also, care must be taken to avoid going through the softer nucleus and puncturing the posterior capsule.
Supracapsular phaco means that we are bringing the cataract nucleus out of the capsular bag primarily with hydro-dissection. We can also use visco-dissection to perform this step, though usually the hydro-dissection is sufficient, Once the nucleus is partially prolapsed above the anterior capsular rim, it can be emulsified quite easily.
The tilt and tumble technique is a type of supracapsular phaco, as is the flip and chop. Both of these techniques will require a sufficiently large capsulorhexis of about 5 mm in diameter. There is no need to make an oversized capsulorhexis of 6 mm or larger, but you must avoid making a small capsulorhexis of 4 to 4.5 mm.
click below to watch the highly efficient method of supracapsular phaco: